Remote Clinical Appeals & Grievances Specialist

Healthfirst; Tennessee; Hybrid; USD 73.000 - 120.000; Vollzeit

Benefits dieser Stelle

Medical coverage

Dental coverage

Vision coverage

401k contributions

Life insurance

Incentive programs

Zusammenfassung

Healthfirst seeks an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution, handling member or provider appeals with regulatory compliance. The role may be remote or on-site at NYC or Lake Mary, FL, with travel to meetings as required.

You will independently research issues, frame decisions from internal policies, and prepare cases for medical review and external appeal processes while maintaining timely documentation and a high standard of quality.

Qualifikationen

• RN, LPN or Dental Hygienist licensure is required.
• Experience in clinical practice with appeals and grievances is preferred.
• Ability to manage multiple caseloads and work in a fast-paced setting.

Aufgaben

• Develop and resolve clinical cases, ensuring regulatory compliance and documentation.
• Prepare cases for Medical Director Review and external appeal processes.
• Research issues, interpret regulations, and communicate with colleagues within timeframes.
• Maintain case notes, summaries and file documentation accurately.

Kenntnisse

Independent work

Detail-oriented

Effective communication

Ausbildung

RN

LPN

Dental Hygienist

Tools

Microsoft Word

Excel

CCMS

TruCare

Hyland

Jobbeschreibung

Healthfirst seeks an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution, handling member or provider appeals with regulatory compliance. The role may be remote or on-site at NYC or Lake Mary, FL, with travel to meetings as required.

You will independently research issues, frame decisions from internal policies, and prepare cases for medical review and external appeal processes while maintaining timely documentation and a high standard of quality.